Global public health has recently been the focus of increasing attention from the interdisciplinary worlds of policy and politics, academia, private foundations, civil society, the media and the general public. This is likely the result of the convergence of a number of seemingly disparate features of the current public health landscape and is not surprising given recent current events – the earthquake in Haiti, healthcare reform in the United States, and aging populations all over the world experiencing rising rates of chronic diseases, such as cancer and diabetes . This article will explore some of the most salient recent trends in global health and its affiliated fields to understand in what direction the discipline is moving and offer some modest recommendations as to how the field may adapt to an increasingly globalized world. This article will focus on education and training, human rights, technology, civil society, new money and public-private partnerships (PPPs) to give the reader, who may not be familiar with the broad scope of this field of study, an overview of some recent developments in global public health and their consequences for practitioners.
The spread of HIV/AIDS, SARS, H1N1 and various non-communicable diseases has confirmed that “diseases do not need visas”. The field of global health has emerged as a significant public health focus, though a clear definition of the discipline remains under debate. Indeed, visionaries such as Julio Frenk see them as one and the same , while others, for example the Consortium of Universities of Public Health have a more complex view in which global health is simultaneously a notion, an objective, and/or “a mix of scholarship, research, and practice” . The definition the group ultimately presented read “global health is an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.” Despite the burgeoning popularity of global health, however one may define it, training and educational opportunities remain relatively scarce. In the United States, for example, only about 20 universities (out of hundreds) offer a graduate degree program in global health – formerly known as “tropical” or “international” health – and programs at undergraduate institutions are few and far between . There are even fewer programs for global health study in developing countries  where the need is arguably greatest. The noticeable recent surges of academic enthusiasm for the field of global health have not been sufficiently matched by significant increases in training opportunities, especially for younger students .
A second concept that has emerged to change the face of global health is that of health as a human right. Often still understood from within its conceptual framework or as solely a process for transformation,  health as a human right has actually become quite mainstream and certainly is increasingly operationalized by a variety of private foundations, bi- and multilateral organizations and governments. Many countries have even incorporated the right to health into their constitution. Development of the rights-based approach came about in reaction to pervasive stigma and discrimination around the early stages of the HIV/AIDS epidemic and has since diffused to many areas of public health, especially within low resource settings. Whether the rights-based approach is used explicitly or implicitly, it is clear that it is more frequently being applied to programming, rules and regulations along with the right to education, employment and development . This focus may have decreased disparities within countries, but strangely enough has the potential to increase certain disparities between countries as some adopt these principles and others do not. It is thus the role of public health practitioners, policy-makers and government officials, to use a human rights framework in his or her approach and to encourage others to do so as well. Only then will this field become fully integrated.
A third and quite transformational evolution in the field of global health has been the development of new technologies, as well as the new use of old technologies in innovative ways. For example, the challenges presented by the disaster in Haiti and the associated public health issues such as water, sanitation and the spread of disease, gave rise to alternative ways to manage crises. Cell phones were especially useful for mapping damage, coordinating relief efforts, reuniting families, donating money and for helping ordinary people find their voices amidst the rubble . Media attention in the form of live feeds and real-time interviews certainly contributed to the world’s understanding of the crisis and their subsequent outpouring of financial, technical and religious support. Apart from the crisis, service provision and data collection is slowly but surely being revolutionized by the use of cell phones to administer checklists and provide real-time training and support . The idea is that better quality data, monitoring and evaluation will yield more effective uses of resources and more successful future programming.
A fourth development has been the rise of civil society, especially international non-governmental organizations (NGOs) or civil society organizations (CSO). Their increasing prominence, connectedness, and centrality to global health priority-setting cannot be understated . The NGO community has successfully lobbied, instructed and altered the work of multilateral, bilateral and government agencies and is global in scope and influence. For example, successful lobbying on drug access and pricing and tobacco advertising has proven “transnationally” transformative in the support of the public interest . Spurred themselves by new technologies , civil society organizations (CSOs) are able to occupy the unique position of both “watchdogs as well as collaborators” . NGOs may have, however, muddied the waters of global efforts towards accountability, though new NGOs have sprung up to monitor the old .
Lastly, the increasing popularity of alternative ways and means to improve global health has generated the need and opportunity for creative new partnerships. For example, private foundations such as the Bill and Melinda Gates Foundation have provided enormous financial support for both mainstream and neglected global health issues from sexual health programs for urban sex workers in India to striving to eliminate onchocerciasis (river blindness) in Colombia . Additionally, public-private partnerships (PPPs) are more often being used to leverage private sector efficiency to solve public sector problems . Both have undoubtedly contributed significantly to the often scattered and uncoordinated field of global health with new reincarnations of functional organizational behavior, technological and human resources development, and program management. The realization of the importance of working with both the public and the private sector is essential to global health practitioners’ effectiveness. The fields of business, international relations and finance have certainly contributed to significant advances in global health and we must learn as much possible from this interdisciplinary collaboration.
In light of the developments discussed above, representing only a select few that I find most illustrative, the evidence that the face of global health has been and still continues to evolve is quite convincing. With such growth and development come both significant challenges and opportunities for both practitioners and the public. We tend to point our fingers, in the event of program failure or frustration, at a lack of resources or of political will. But I point mine – in the spirit of constructive criticism – at the scattered understanding and capacity of this emerging field. The palpable lack of accord in priority-setting and the dearth of training opportunities for interested young people have handicapped our ability to tackle the real public health issues. The current relative lack of consensus and preparedness in the wake of expanding interest in and commitment to global health is concerning. It seems, therefore, critically important to cultivate academic, civil society and political enthusiasm for the topic in order to assure that future generations have the focus, capacity, and knowledge necessary to set priorities and work together.
The field of global health is currently almost exclusively pursued at higher institutes of learning in the developed world, to its detriment. With decreasing life expectancy in Sub-Saharan Africa, an obesity epidemic in the United States, and indigenous populations all over the world suffering significantly poorer health than their non-indigenous counterparts, public health should be one of the most active areas of work and study in our world today. However, both low- and high-income settings lack the training opportunities needed in emerging public health fields. Spatial and geographic methods, low-resource-appropriate health technology, complex data management, monitoring and evaluation, demographics of aging, methods for accountability and a better understanding of health economics, systems and policy are just a few of these neglected sub-fields. The challenge is therefore to translate new and welcome enthusiasm into the skills and capacity to enable young people to contribute to the field in a both a constructive and a cooperative manner.
Most importantly, the field of global health should, indeed, be global . It should certainly not be simply a discipline intended to increase a university’s prestige, attract funding, or ever perpetuate the image of professionals from low-income settings as not working in “global health” . It is therefore necessary to increase training opportunities in the low-resource-settings themselves – not for international students, but for locals – and to improve programs already in existence so that they may meet growing needs and interests. New and creative approaches are needed, however, as currently employed programs and incentives do not seem always to attain their desired results . For example, Dr. Lincoln Chen and colleagues in 2004 proposed a health systems approach to improve workforce capacity in low-income settings using a multidisciplinary local approach benefiting from “appropriate international reinforcement” i.e. supplemental funding . Their suggestion to mobilize a collaborative strategic plan can certainly be applied to other aspects of training in global health whether it be integrating human rights into government policy, collaborating effectively with civil society, human resources strengthening by task shifting, or improving efficiency through new partnerships and technologies. The framework’s call for “immediate action backed by simultaneous learning” certainly applies to the need for improved training and capacity building in all areas of the discipline.
The birth of global health and its growing pains can be seen as both an opportunity and a challenge in our globalized world of scarce resources. The changes in the discipline described above can be seen as wonderful developments to be taken advantage of. It is important in discussions of global public health not to bemoan our lack of resources or lack of political will as barriers to achieving our goals. More important is the need for pertinent training  and an ability to integrate solutions and work together, whether it be to combat the emergence of a highly infectious disease or disseminate a new checklist to improve patient care. All worthwhile initiatives lack funding, but the difference between those that achieve something and those that do not is the way in which they use the limited resources they have. Nowadays, the field of global health can boast enormous enthusiasm, media coverage, technological partnerships and advancement, human rights street cred, sophisticated techniques for data collection and analysis, and reach far across sectors from business to anthropology. We therefore must stop bemoaning what we don’t have and cultivate what we do.
Laura Nolan Khan
Department of Global Health and Population,
Harvard School of Public Health
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